Indicators for Universal Health Coverage: can Kenya comply with the proposed post-2015 monitoring recommendations?
© Obare et al.; licensee BioMed Central. 2014
Received: 19 June 2014
Accepted: 2 December 2014
Published: 20 December 2014
Universal Health Coverage (UHC), referring to access to healthcare without financial burden, has received renewed attention in global health spheres. UHC is a potential goal in the post-2015 development agenda. Monitoring of progress towards achieving UHC is thus critical at both country and global level, and a monitoring framework for UHC was proposed by a joint WHO/World Bank discussion paper in December 2013. The aim of this study was to determine the feasibility of the framework proposed by WHO/World Bank for global UHC monitoring framework in Kenya.
The study utilised three documents—the joint WHO/World Bank UHC monitoring framework and its update, and the Bellagio meeting report sponsored by WHO and the Rockefeller Foundation—to conduct the research. These documents informed the list of potential indicators that were used to determine the feasibility of the framework. A purposive literature search was undertaken to identify key government policy documents and relevant scholarly articles. A desk review of the literature was undertaken to answer the research objectives of this study.
Kenya has yet to establish an official policy on UHC that provides a clear mandate on the goals, targets and monitoring and evaluation of performance. However, a significant majority of Kenyans continue to have limited access to health services as well as limited financial risk protection. The country has the capacity to reasonably report on five out of the seven proposed UHC indicators. However, there was very limited capacity to report on the two service coverage indicators for the chronic condition and injuries (CCIs) interventions. Out of the potential tracer indicators (n = 27) for aggregate CCI-related measures, four tracer indicators were available. Moreover the country experiences some wider challenges that may impact on the implementation and feasibility of the WHO/World Bank framework.
The proposed global framework for monitoring UHC will only be feasible in Kenya if systemic challenges are addressed. While the infrastructure for reporting the MDG related indicators is in place, Kenya will require continued international investment to extend its capacity to meet the data requirements of the proposed UHC monitoring framework, particularly for the CCI-related indicators.
Background on Universal Health Coverage
Universal Health Coverage (UHC) has been defined as providing access to needed health services without incurring financial hardships for the whole population , and is receiving renewed attention at both global and national levels. In 2005 the Member States of the World Health Organization (WHO) adopted a resolution encouraging countries to develop health financing systems aimed at achieving UHC . Recently, the quest for countries to achieve UHC has received significant support from key global players, with the WHO, World Bank and United Nations General Assembly all making commitments to the UHC agenda ,. The fact that millions of people still lack access to basic health care services motivates this attention . Similarly, the costs associated with utilising health services place an immense financial burden on many households. Global estimates indicate that every year, nearly 150 million people experience catastrophic health expenditure where household out-of-pocket payments for health care consume such a proportion of their income that it forces them to forego other goods and services , while 100 million are pushed into poverty .
UHC is increasingly embraced at a global level as a priority in the post-2015 development agenda ,. Health is acknowledged as essential for human welfare and sustained economic and social development . When people have poor health, with lack of health service being a one of the contributing factors, they often are vulnerable to poverty. At the same time, people seeking health services may incur impoverishing health costs . This paradox provides an affirmation of the critical link between health, sustainable development and economic growth . Ill health affects productivity and diverts households’ income to seeking health services, thus negatively impacting on economic and social development ,. Achieving UHC is primarily an issue of equity, ensuring that people can access the health services they need to keep them healthy and productive, while at the same time, safeguarding them from being pushed into poverty due to out-of-pocket health expenditures . UHC strategy will contribute to improving health as well as reducing the vulnerability to poverty; thus contributing to the post-2015 agenda on sustainable development.
To progress towards UHC, countries will need to concurrently undertake health financing reforms as well as comprehensively address health systems service delivery challenges ,. According to the WHO 2010 report, the UHC target is to progressively expand the range of health services offered, the proportion of the population covered and the proportion of health cost covered to reduce the financial burden on households . The WHO 2010 report identified three critical areas for health financing reforms. These reforms require raising necessary health funds to offer health services, shifting to viable pre-payment methods and improving efficient and equitable use of available health resources . The strategies that countries adopt to achieve UHC vary . Country-specific contexts i.e. disease burden, health system, economic as well as political factors, will greatly influence the policy choices, but in spite of the varied approaches to achieving UHC, the three dimensions of UHC will apply across all contexts. These cross-cutting aspirations of UHC form the foundation for measuring progress.
For WHO, monitoring progress towards UHC is one of its research priorities, and will facilitate assessment and tracking of strategies implemented and their outcomes. A global monitoring framework will allow joint learning and sharing of experience and knowledge on UHC implementation across different contexts, and a common and comparable approach in assessing UHC progress is currently being developed ,.
In recent years, consultative meetings have been conducted to develop a common mechanism of monitoring progress towards UHC. These meetings addressed the concepts of UHC that will be measured, and described the potential indicators to be utilised -. There is a consensus that measurement of UHC will primarily focus on the level and distribution of the service coverage and financial protection as well as ensuring equity . The culmination of these discussions resulted in the release of the joint WHO/World Bank paper in December 2013, proposing a framework for tracking UHC progress at a national and global level. The aim of the framework is to foster a common approach to measuring country progress against standardised international indicators. This will facilitate comparison of the progress made towards UHC among different countries so that they can learn from each other.
Recent studies on the measurement of UHC progress have explored possible indicators for UHC, the availability of the indicators in low income countries, and validity of commonly proposed indicators and the data sources -. The approaches of these studies, however, were not based on the joint WHO/World Bank framework. In order to inform the continuing development of that framework, this study seeks to assess Kenya’s ability to report on the WHO/World Bank UHC indicators. The paper describes the current context of UHC in Kenya; identifies the available tracer indicators for the proposed framework; identifies the data sources for the indicators; and describes the factors that will affect the feasibility of the WHO/World Bank framework in that country. The findings from this study will contribute to the on-going discussions on measuring progress toward UHC by highlighting the factors that will affect implementation and applicability of the proposed framework in Kenya.
Background on the demographic and socio-economic status of Kenya
Summary of demographic and socio-economic indicators for Kenya
Total population (2012)
Urban population (2011)
Life expectancy at birth (years) (2012)
Total fertility rates (births per woman) (2014)
GNI per capita (2012)
GDP growth (2012)
Unemployment rates (2008)
Population living below the poverty line (2012)
Overview of Kenya’s Health System
The country grapples with a high disease burden, of which the traditional communicable diseases are the major cause . The Global Burden of Disease Study (2010), for example, indicates that communicable diseases, maternal, neonatal and nutritional conditions remain the top ten leading causes of Disability Adjusted Life Years (DALYs) in Kenya . However, non-communicable diseases (NCDs) and injuries are increasingly becoming an important contributor to the disease burden . Further analysis suggests that, apart from HIV/AIDS, NCDs and injuries represent the leading cause of DALYs among adults . As the country makes gains in the control of HIV/AIDS, the significant burden of NCDs and injuries among adults is thus a growing concern among health policy makers .
Service delivery and health outcomes
In Kenya health services are provided by four main sectors: public, private, faith-based and non-governmental organisations (NGOs). The private and faith-based institutions are a mix of profit and not-for-profit agencies. The public sector operates the largest share of healthcare facilities in the country, and is the major health service provider in the rural areas ,. As such, access to health services by the majority of Kenyans is largely influenced by the functionality of the public health sector.
Summary of key Kenyan health sector indicators values in comparison to average values for low income countries
Average for low income countries
Health Service delivery
Births attended by skilled health personnel (%) (2005–2012)
Contraceptive Prevalence (%) (2005–2012)
Neonates protected at birth against neonatal tetanus (%)(2011)
DPT3 Immunisation coverage among 1-year-olds (%)(2011)
Density of nursing and midwifery personnel per 10 000 population
Hospitals (per 10 000 population)
Median availability of selected generic medicines in public sectors (%)
Total expenditure on health as a percentage of gross domestic product (2010)
Kenya NHA and WHO
Per capita expenditure on health expenditure on health at average exchange rate (US$)
General government expenditure on health as a percentage of total expenditure on health
Government expenditure on health as a percentage of total government expenditure
Private expenditure on health as a percentage of total expenditure on health
Out-of-pocket expenditure as % of private expenditure on Health
Maternal mortality ratio (per 100 000 live births) (2010)
Under five mortality rate (per 1,000 live births) (2011)
Adult mortality rate (probability of dying between 15–60 years of age per 1000 population) (2011)
Male = 346
Male = 288
Female = 294
Female = 245
WHO/World Bank UHC monitoring framework
Global-level framework for monitoring UHC
Achieve UHC – All people should have access to the quality, essential health services they need without enduring financial hardship
By 2030, at least 80% of the poorest 40% of the population have coverage to ensure access to essential health services
By 2030, everyone (100%) has coverage to protect them from financial risk, so that no one is pushed into poverty or kept in poverty because of expenditure on health services
Health service coverage indicators
1. Aggregate: A measure of MDG-related service coverage that is an aggregate of
2. single intervention coverage measures
3. Equity: A measure of MDG-related service coverage for the poorest 40% of the population
1. Aggregate: A measure of CCIs-related service coverage that is an aggregate of single priority interventions to address the burden of NCDs, including mental health and injuries
2. Equity: A measure of CCI service coverage for the poorest 40% of the population
Financial risk protection indicators
1. Aggregate: A measure of the level of household impoverishment arising from out-of-pocket expenditures on health, equal to the ratio of the poverty gap in a world without out-of-pocket payments to the actual (larger) poverty gap.
2. Aggregate: The fraction of households incurring catastrophic out-of-pocket health expenditures.
3. Equity: The fraction of households among the poorest 40% of the population incurring catastrophic out-of-pocket health expenditures.
Literature search strategy
Summary of the search terms used
“health sector reforms”, “universal health coverage”, “health financing” “universal access to health care” “health insurance”, “out-of- pocket expenditure”, “health care cost” “Health system reforms”
“Kenya”, “developing countr*”, “low income countr*”,
“health information system” “health metrics” “monitor* universal health coverage” “health indicator*” “measur* universal health coverage” “MDG monitor*” “NCD indicator*”
Selection of articles
The search was conducted purposively to identify key relevant resources to answer the research objectives. The abstract and summaries of the identified articles and reports published in English were reviewed to determine the relevance of the documents in relation to the research question. A total of 228 documents were retrieved into Endnote referencing software. The retrieved documents were then reviewed to identify and exclude duplicates, and then to select the sources providing information on relevant potential data sources, using the following inclusion criteria:
Published in the year 2000 onwards
Published in English Language
Research studies conducted in Kenya
Literature addressed health service coverage, financial risk protection, measurement of UHC and health information systems
Kenyan Government policy documents and reports that addressed access to health services and health information systems
New developments on the WHO/World Bank UHC monitoring framework
Since commencing the study, the WHO/World Bank framework was recently revised to capture the feedback received from various stakeholders . The principles and the concepts to be monitored i.e. level and distribution of service coverage; financial protection and equity remain the same. The revised framework adopted limited changes in terms of the indicators to be used, and these have been incorporated into our analysis. However the presentation of the indicators has been reconfigured. Firstly, the health services coverage indicators, initially presented as aggregate MDG-related and CCI-related measures, have been integrated to represent aggregate prevention and treatment measures. Secondly, equity measures are to be disaggregated by place of residence, gender, and wealth quintile across the whole population. Lastly, the financial protection coverage indicators have been refined to measure the “households protected” from, rather than “households incurring” impoverishing and catastrophic expenditure due to out-of-pocket health expenditures ,. Additional file 4 summarises the revised WHO/World Bank framework for monitoring UHC.
This study utilised both versions of the joint WHO/World Bank framework ,, together with the report from the Bellagio meeting . We have retained the structure from the first version of the framework to distinguish between data sources and gaps that have been established for the current MDG-related measures and those required for proposed CCI-related measures. The revised framework was utilised for the analysis of the new dimensions of coverage, disaggregation of equity measures, and the shift to reporting on “households protected”.
Findings and discussion
UHC in the Kenyan context
Summary of UHC aspects in the Kenyan context
Access to needed services
• The right to health services by all Kenyans is articulated in the constitution
• A standard Kenya essential health package is being implemented and has included interventions for non-communicable diseases and injuries as well.
• The availability of health facilities and services are limited, more so for the rural population.
• The range and quality of health services offered are limited.
• Cost is a key barrier to accessing health services.
Financial risk protection
• Existing health financing mechanisms offer very limited financial risk protection.
• Out of pocket expenditure is major source of health sector financing in the country.
• Nearly 10% of Kenyans have access to any form of health insurance. Majority of the health insurance schemes require co-payments for medicine or certain outpatient and diagnostic services thus offering limited protection.
• Kenyan households incur impoverishing and catastrophic health expenditure. Estimates suggest that nearly 1.5 million households are pushed below the national poverty line due to health care payments.
• Health sector is inequitable. The distribution and utilisation of health services favour the wealthier and urban populations in the country.
Policy framework for UHC in Kenya
The country has yet to establish a formal policy declaration on UHC that is entrenched in legislation. The current Kenya Health Policy 2012–2030 is the most detailed policy document that addresses certain aspects of UHC . The policy objective “to attain universal coverage of critical services that positively contribute to the realisation of policy goals” provides a documented commitment to achievement of UHC for all Kenyans . Similarly, the country has undertaken various strategies to facilitate improved access to affordable health services and address the high disease burden ,. The most significant strategies in relation to UHC are the two attempts to transform the country’s NHIF into a compulsory social health insurance ,. The objective of these proposed amendments was to shift the current health financing arrangements to prepayment mechanisms, reducing the dependence on out of pocket payment and mobilising more funds into the health sector through membership contributions. The proposed amendments were not adopted into legislation due to the lack of finances to cater for the cost of the scheme, and opposition from a section of professional bodies, employers and the private health sector ,. Although the proposed amendments were not adopted into legislation, implementation of social health insurance remains a priority agenda in the Ministry of Health’s strategic plan . Discussions are still ongoing to determine a viable approach of ensuring that Kenyans have access to social health insurance coverage.
Feasibility of the proposed UHC monitoring framework in Kenya
MDG-related service coverage indicators
Availability of MDG related service coverage indicators and their data sources
UHC Health service coverage indicators indicator
Potential tracer indicators for aggregate MDGs-related interventions (n = 22 indicators)
Aggregate: A measure of MDG-related service coverage that is an aggregate of single intervention coverage measures
Need satisfied for family planning
Routine facility data/KDHS.
Skilled birth attendance
DPT3 immunisation coverage
Serious acute child illness coverage (Percentage of Health Facilities providing treatment as per the IMCI guidelines)
Supervision reports/Kenya service provision assessment survey
Household ownership of insecticide treated nets (ITNs)
Malaria Indicator survey
Tuberculosis treatment coverage
TB programme reports
Ante-retroviral treatment (ART) coverage
routine facility data (NASCOP reports)
PMTCT service coverage
Additional coverage indicators
routine facility data/KDHS
ANC 4+ visits
Postnatal care visit within two days of childbirth (%)
Measles, BCG, polio, hepatitis B, Influenza coverage among older people
Suspected pneumonia treated with antibiotic
routine facility data/KDHS
Diarrhoea treated with oral rehydration salts (ORS)
Coverage of exclusive breast feeding
Intermittent prevention treatment (IPT) during pregnancy
Malaria programme reports/ malaria indicator survey
Fever treated with antimalarials
Routine facility data/Malaria indicator survey/KDHS
Households with indoor residual spraying (IRS).
Malaria indicator survey
TB case detection rate (the number of estimated new TB cases detected in a given year using the DOTS approach) expressed as a percentage of all new TB cases)
TB programme reports
Male circumcision rates
Condom use at higher risk sex
Equity: A measure of MDG-related service coverage for the poorest 40% of the population
Surveys mentioned above.
Frequency of various data sources in Kenya
Kenya AIDS Indicator survey (KAIS),
Kenya demographic health survey (KDHS),
2008/2009 follow up of 2003 survey
Kenya service provision assessment survey (KSPA)
2010 survey was a follow up of 2004,1999 survey
Kenya malaria indicator survey
2010 follow up to 2007
Kenya national health accounts survey
2009/10 follow up of 2005/06 survey
Kenya household health expenditure and utilisation survey
2007 follow up to 2003 survey
2009 follow up to 1999 census
Measurement of the equity indicator for MDG-related service coverage will be possible from the following surveys: Kenya AIDS Indicator survey (KAIS), Kenya demographic health survey (KDHS), Kenya service provision assessment survey KSPA and the census-collect primary data on the socio-economic status of the respondents ,. This will allow for the disaggregation of data on socio-economic status and measuring MDG service coverage among the poorest 40% of the population. However the primary data on socio-economic status are currently only updated every 5–10 years, depending on the periodicity of the surveys.
The revised WHO/World Bank UHC monitoring framework has broadened the dimensions of equity measures to include place of residence and gender in addition to the wealth quintile. But in the country’s current reporting processes, most data from facilities are aggregated at district level. Information available at national level will therefore be aggregate district measures, and further information on place of residence may be more cumbersome to retrieve. Furthermore, due to the frequent mobility of Kenyans in both urban–rural migrants and the pastoralist communities, the place of residence may be difficult to ascertain for the purposes of measuring equity .
CCI related service coverage indicators
Availability of CCI related service coverage indicators and their data sources
UHC Health service coverage indicators
Potential tracer indicators for the aggregate CCIs-related service coverage measures (n = 27 indicators)
Aggregate: A measure of CCIs-related service coverage that is an aggregate of single priority interventions to address the burden of NCDs, including mental health and injuries
Percentage with hypertension diagnosed and receiving treatment
Probability of dying between the exact ages of 30 and 70 from any of cardiovascular disease cancer diabetes or chronic respiratory disease
Age-standardised prevalence of diabetes (based on HbA1c levels), hypertension, cardiovascular disease and chronic respiratory disease
Age-standardised mean population intake of salt (sodium chloride) per day in grams in persons aged 18+
Prevalence of persons aged 18+) consuming less than five total servings (400g) of fruit and vegetable per day
Fraction of calories from added saturated fats and sugars
Hepatitis B vaccination coverage
Percentage of the population that is overweight and obese
a survey proposed
Prevalence of insufficient physical activity
Human papilloma virus (HPV) vaccination coverage
Percentage of women with cervical cancer screening
routine facility data
Arthritis treatment coverage
Road traffic deaths per 100,000
Vital registration and Traffic department records.
Harmful use (consumption) of alcohol
Current use of any tobacco product
Smoking cession rates
Angina treatment coverage
Cardiovascular diseases preventive drug therapy for high risk groups
Diabetes treatment coverage
Coverage of pain relief
Asthma/COPD treatment coverage
Depression treatment coverage
Cataract surgery coverage
Coverage with rapid emergency response
Equity: A measure of CCI service coverage for the poorest 40% of the population
Financial risk protection indicators
Available financial risk protection indicators and their data source
Financial risk protection coverage indicators
Aggregate: a measure of the level of household impoverishment arising from out of pocket expenditures on health, equal to the ratio of the poverty gap in a world without out of pocket payments to the actual poverty gap
Kenya household health expenditure and utilisation survey
Aggregate: the fraction of households incurring catastrophic out of pocket health expenditures
Conducted every 5 years last survey was conducted in the year 2013
Equity: The fraction of households among the poorest 40% incurring catastrophic out-of-pocket health expenditures.
Key Constraints that will affect feasibility of the framework
Weak health information system
The implementation of the proposed UHC monitoring framework hinges on the functionality of the country’s health information system, which will play a critical role in generating valid and reliable data that can be benchmarked and tracked to monitor UHC progress ,. Currently, the country health information system experiences several challenges that impede its ability to generate the required information to meet both national and global reporting mechanisms. The health information system lacks adequate resources in terms of human resource, budget and infrastructure as well as data collection and reporting tools to conduct its functions . A recent technical report suggests that the country’s health information system is not adequately responsive to meet the evolving needs for data reporting . The lack of an adequate health information system has hindered the capacity of the Ministry of health to adequately steer resource allocation in line with its policy goals and objectives . Consequently, the country urgently needs to address these contextual challenges. But if the implementation of UHC is driven with the necessary technical support, it will facilitate the generation of reliable health information. This has the potential to enable policy makers to identify service coverage gaps, scale up and improve health services effectively, and inform the UHC monitoring process at country and global levels.
Good quality data is critical to the success of monitoring progress towards UHC. The five key critical dimensions of quality include accuracy, completeness, timeliness, consistency and accessibility ,. Based on these five dimensions, a series of studies suggest that the quality of data generated at various levels of the health information system is inadequate, with reports of inaccurate data entry at facility level, incomplete data and late reporting ,,,. There is an urgent need to address this issue since routine facility data will play a more pivotal role in the success of monitoring progress towards UHC.
Fragmented health information reporting system
The available indicators are captured across several data sources and programmes within the country’s health information system. The donor investments in monitoring of the health MDGs resulted in several parallel reporting channels created to meet various donor reporting needs. However, there is limited coordination across the various reporting channels . In certain instances data reporting bypasses the Ministry of Health reporting channels to meet donor requirements . This creates challenges in the retrieval of data for the indicators and discrepancies in data generated. The fragmentation will affect the availability of reliable, consistent and timely generation of data for the UHC indicators.
Intervals of data availability
The national surveys are often a preferred data source since they provide better quality data and are more generalizable to the whole population. However, the frequency of conducting these surveys is varied and hence has an important implication on the availability of data. These surveys are conducted in the country on average every 3–5 years. Furthermore, the roll out of individual surveys and the frequency of these surveys are not synchronised ,. Results of different surveys measuring different aspects of UHC indictors will be available at different times. This means the country may only have the capacity to sufficiently report on some indictors every five years or more. In the event that the global monitoring process requires more frequent reporting, i.e. shorter that the five period, the country’s capacity to report will be limited to facility data.
The WHO/World Bank focus on developing a comprehensive monitoring framework for UHC within the Sustainable Development Goals has exposed not only the weaknesses of the health information systems in developing countries, but also the vulnerabilities of the health systems that underpin them. The aspiration to provide access to health services to all Kenyans in a bid to spur social and economic development has been articulated in several government policies. The Ministry of Health has undertaken several piecemeal strategies to facilitate the expansion of service delivery and affordability of health services ,,. However, these policies have not been linked to appropriate operational plans and budget allocations, resulting in weak policy implementation. Health policy priorities, budgets and implementation have been significantly affected by changes in political leadership and direction ,,. Moreover, the policies have mainly focused on health financing without adequately addressing other health systems issues that limit service delivery ,. The consequence of this limited policy approach undertaken with its weak policy implementation has resulted in limited progress towards UHC. Access to health services remains limited, inequitable and expensive for the majority of the population.
The problem for Kenya—and many other low and middle income countries—is cyclical. The implementation of an effective monitoring framework to monitor progress towards UHC assumes a functioning health system that can sustain effective health information data collection and reporting. There needs to be political commitment to the concept of UHC before this can happen: data collection, particularly where it is of dubious quality, will at best point to weaknesses, but not drive their reform. Lack of strong stakeholder engagement and commitment to achieving UHC remains an important impediment to Kenya’s progress ,. Countries that have had high level political commitment like Ghana, Vietnam, Rwanda and Mexico have made significant progress in increasing UHC in the last decade . This has facilitated the necessary leadership, multi-sectoral cooperation and budgetary allocations to propel the UHC agenda ,. There is increasing evidence to suggest that even low income countries can achieve UHC, if the appropriate policy decisions and investments are undertaken .
In Kenya, the agenda to achieve UHC has largely been driven by the Ministry of Health, but the Ministry does not have sufficient direct influence on the country’s budget, development or political agenda to bring about the whole of government changes required for UHC . The Ministry’s policies will only be feasible if it can secure the support and prioritisation of UHC by the President and Parliament of Kenya. Prioritisation of UHC in the post-2015 Sustainable Development agenda offers a global profile for UHC reforms, and an opportunity to generate stronger stakeholder commitment and momentum for implementation of UHC.
The results of this study have clear implications: with the global MDG focus on HIV/AIDS, tuberculosis and malaria, the monitoring and reporting mechanisms for those conditions have been developed and institutionalized. In contrast, the systems for reporting on chronic conditions and injuries are ad hoc, uncoordinated, inconsistently reported and not always representative. Extending the success of MDG monitoring will require not only improvements in health information systems, but the comprehensive development of strategies to address this growing non-communicable burden of disease. This has implications not only for Kenya, but also for the international community.
The implementation of MDG programmes and the internationally driven national surveys such as the KDHS, KAIS and the Kenya Malaria survey have established an infrastructure for reporting on most of these indicators. The surveys have the potential to be adapted to include CCI indicators, financial risk protection and the specific equity measures, but financial considerations will limit the frequency of their application. There is a need to set up additional routine mechanisms for monitoring CCI indicators, extending monitoring into the private sector, and investing in the health information system to enhance the generation of good quality data. This will be critical for supporting a meaningful and informative UHC monitoring and policy decision processes.
With aggregated reporting recommended in the evolving WHO/World Bank UHC monitoring framework , care needs to be taken that the existing capacity to report on both MDG prevention and treatment service coverage indicators does not conceal the inadequacies in reporting systems for the new focus—CCI interventions. Using the first version of the UHC framework, that distinguishes MDG and CCI service coverage indicators, we have clearly demonstrated the specific gaps in relation to CCI indicators that need to be addressed.
These results are consistent with the findings of other studies that have been conducted on monitoring UHC: other low income countries share Kenya’s limited ability to report on the indicators for CCIs ,. Yet even with the monitoring of MDGs, many countries have not been able to report on selected indicators . And although this study found that several of the MDG-related indicators were available in Kenya, the reliability, comprehensiveness and timeliness of the data has been a key challenge for the health information system ,.
As global discussions on UHC and post 2015 development agenda are ongoing, it will be critical to make plans on how the required data can be generated by Kenya and other developing countries in similar scenarios. Post-2015 planners now need to be considering how low-income countries will be supported in terms of technical expertise, financial resources, and the extensive sensitisation and training of primary data collectors on the new framework. The WHO and World Bank, if they see the need for such a level of reporting for UHC, need to consider the implications of development assistance required for such substantial infrastructure—even in emerging middle income countries like Kenya. The global community will need to engage with individual countries to establish to what extent each can realistically report on the framework, and to identify the extent of investments required.
The implementation of the proposed UHC monitoring framework in Kenya will be beneficial for the country to assess its progress. To some extent, the global focus will drive domestic planning and investment for the indicators not currently available in Kenya. Kenya, like any country, will have to make policy decisions and trade-offs on how to approach the expansion of UHC to suit its context . The monitoring and assessment of the process will be necessary to steer the country’s process . The framework has clearly prioritized both health service coverage and financial protection for the whole population, but for Kenya, this should not be equated merely to establishing social health insurance as captured in some of the Ministry of Health policy documents ,. The focus of UHC monitoring on health outcomes, financial protection and equity has the potential to galvanize reform for policy makers in the country. In anticipation of this global momentum, Kenya needs to urgently develop a comprehensive policy framework that can pragmatically move the country forward in its quest for UHC.
The funding for Go4Health, a research project of which this analysis was part, was provided by the European Union’s Seventh Framework Programme (grant HEALTH-F1-2012-305240) and by the Australian Government’s NH&MRC-European Union Collaborative Research Grants (grants 1055138). Further acknowledgement goes to the Australian and Kenyan governments for nomination and funding of Valerie Obare for her MIPH program at the University of Queensland. We thank Titilayo Falade for proof-reading and editing of the document.
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